Sunday, April 29, 2007

Changes need to be made in how Florida treats the mentally ill. I grew up in Christiansburg and Blacksburg, Va. The tragedy at Virginia Tech hit close to home for me on many levels.

Mass killer Seung-Hui Cho is another example of why the public needs to be educated, brought out of the "dark ages" concerning the treatment of mental illness.

Just like cancer, diabetes or heart disease, mental illness is a medical condition, a very serious medical condition. It is not something a person is too weak or not moral enough to control.

When people with diabetes experience the symptoms of their disease, they are immediately treated with insulin or sugar to prevent the most serious consequences of coma or death. When people show up at an emergency room with chest pain, they are immediately triaged, given an EKG and baby aspirin to prevent a full coronary.

But when mentally ill people ask for help at a mental-health facility in Florida because they are experiencing new symptoms or an increase in the intensity of their illness, the response is, "Come back if you become suicidal or homicidal." I cannot begin to understand the reasoning behind a professional telling a person in crisis, asking for help, "You're not sick enough yet. Come back when you have a plan for suicide or a desire to kill." Is that what professionals call "rational thinking"?

There needs to exist in mental-health facilities in Florida a standard triage protocol as exists in all emergency rooms. When mentally ill people ask for help because their medication is not working, they are experiencing new or an increased intensity in the symptoms of their illness, help should always be available. They should never be turned away.

Who can say that by the time a person reaches the point of suicidal or homicidal thoughts taking form, they will continue being able to reach out for help before a tragedy occurs? The nation saw the answer to that question at Virginia Tech.

Those who do understand the problems in Florida's mental-health facilities suggest the solution is too costly. State mental-health facilities are understaffed; personnel are underpaid and overburdened. My response is, "one ounce of prevention is worth more than one pound of cure." Prisons for mentally ill inmates, lifetime incarcerations and the loss of productive citizens like those victims at Virginia Tech cost the state and the federal government far more than allocating more money for psychotropic medications and treatment.

Please do not wait one more day, one more suicide or one more tragedy to make the needed changes. Educate the public and allocate the funding today.

For mentally ill inmates placed in solitary confinement at the Volusia County Branch Jail without clothing to prevent suicide, the experience is frightening.

And demeaning.

But the practice is commonly used in jails and prisons throughout the country, and what some lawyers find most troubling is that the practice is used for people who have yet to stand trial.

"Telephones constantly ringing. Other inmates screaming. Sleep is difficult," inmate Brett Roberts testified during a court hearing on his treatment Wednesday. "I began to bang my head on the door, and I was told by an officer the governor was there to evaluate me for the death penalty."

Human rights activists say mentally ill inmates, who are increasingly finding themselves in county jails as social service budgets are slashed, are at special risk of abuse. Roberts' claims of taunts by those watching him, including jokes about his genitals, are plausible, they said. Prison officials did not address his specific claims, but said protocols were followed.

Calling for change, an attorney with the National Prison Project of the American Civil Liberties Union said Thursday there are alternatives to "stripping a person," including giving inmates suicide-proof gowns. Other options include closer monitoring of possibly suicidal inmates and building cells that make suicide "very difficult."

But such care is staff-intensive and costs more.

"That's why many resort to the far-cheaper option of throwing someone naked into a bare concrete cell," said David C. Fathi, who has brought lawsuits against jails and prisons throughout the country over how mentally ill people are treated in confinement.

In calling jails and prisons "asylums of last resort," Fathi says cost is most often the reason prisoners are held naked, a practice the group finds inhumane and unnecessary. An appeals court recently compared the practice "to a 1930s Soviet gulag," he said.

Roberts, 26, of Titusville spent a month locked up at the county jail for a violation of probation. There was no indication Roberts, who was first diagnosed with bipolar disorder at 19, was psychotic or a danger to himself or others when he was moved here Feb. 12, according to testimony.

He'd pleaded no contest to a charge of fleeing from officers at a traffic stop and got probation. He was doing well and holding a job.

"People couldn't even tell I was mentally ill," Roberts said.

But when his court-ordered urine sample tested positive for marijuana, he was sentenced to spend six months in the county jail.

Within two weeks, paranoia and delusions that he was going to be killed prompted officials to move Roberts into seclusion. He was placed in a bare cell with a bunk, a toilet, a sink and no movable objects. The medication he got was not what Roberts had requested, and jail doctors never checked with the inmate's physician, he testified.

At times, Roberts testified, he was strapped into a restraint chair and sprayed with a chemical stunning agent because he did not comply with corrections officers. He refused to take his medication, according to testimony.

"He didn't start to get bad until he came to Volusia County," said Virginia Chester, his assistant public defender.

She argued Roberts should complete his sentence at home, claiming the mental breakdown was preventable and his civil rights were violated.

Circuit Judge William Parsons had ordered Roberts released last month until a hearing to determine whether he endured cruel and unusual punishment.

But the judge found the way Roberts was treated was neither cruel nor unusual.

"What does the jail do?" he pondered.

How Roberts was handled "beats the heck out of hanging yourself," he said.

He found care was taken to avoid injury to Roberts. There was no evidence his mental condition worsened because of a change in his medication, the judge said in disagreeing that a constitutional violation occurred.

All agreed, including the county's head of inmate mental-health treatment, who testified jail is not the place for those proven to be mentally ill.

But Dr. David Hager, director of mental-health services for Prison Health Services, defended the psychiatric treatment, saying Roberts was medicated under approved practices. Hager saw Roberts three times at the jail and said he had started "to stabilize."

Asked by attorney Chester if his treatment was humane, Hager answered, "That's a difficult question to answer in a corrections setting. A correctional setting is a different world, with different priorities."

Prosecutor Carine Jarosz told the judge Roberts shouldn't be allowed to use his mental illness as an excuse.

"He still did the crime," she said. "And he still needs to be punished accordingly."

The American Civil Liberties Union has called for reform of how mentally ill inmates are treated. A federal judge in New York is reviewing the settlement in a lawsuit that could impact how mentally ill inmates are treated in other states, including Florida, in the future.

The New York agreement calls for extensive reviews of all prisoners sent to solitary confinement.

The National Prison Project's Fathi said more reform is needed.

"The fact that so many (people with mental illness) end up in jails and prisons because there's no place else for them needs to change."

Wednesday, April 25, 2007

New York State would more closely scrutinize its use of solitary confinement for mentally ill prison inmates under the proposed terms of a legal agreement scheduled for review by a federal judge on Friday.

New York is one of several states that have faced lawsuits over the means used to punish mentally ill prisoners, and, under a settlement reached last week, it has agreed to consider changes in how it uses solitary confinement as a disciplinary measure with the mentally ill.

Many advocates hail the agreement as a watershed in prison reform because of the effects long sentences in isolation have had on the most vulnerable prisoners, including suicide and self-mutilation.

Some mentally ill inmates serve months to years in punitive segregation, locked up for 23 hours a day and sometimes restricted to a diet of cabbage and a pasty flour loaf three times daily for up to 30 days for misbehaving.

Disability Advocates Inc. and the Legal Aid Society of New York sued the state over the practices five years ago, and the resulting agreement goes before Judge Gerard E. Lynch of the Southern District of New York on Friday for final review.

If the agreement is approved, as expected, the state will not be barred from the use of solitary confinement, or punitive segregation, to discipline mentally ill prisoners, but it would have to provide far more assessment and services for mentally ill inmates in solitary. In addition, the state would be required to review the reasons for and the length of proposed segregation sentences.

Many mental health advocates believe that the New York settlement will create pressure on other states to review their policies of confining mentally ill prisoners.

Others, including state lawmakers and advocates, said the agreement was only a small step toward stopping inhumane treatment of these prisoners. Many of those advocates were particularly disheartened last fall when Gov. George E. Pataki vetoed a bill that would have banned the use of solitary confinement for the mentally ill in New York.

"We see the settlement as a step in the right direction because it provides additional resources and services for treating the mentally ill in prison," said Robert Gangi, executive director of the Correctional Association of New York, an advocacy group that is now lobbying the new administration in Albany to stop sending mentally ill prisoners into isolation. "But it falls far short of the policy changes that are needed to ensure humane and appropriate treatment for all the mentally ill people in prison."

In New York, with one of the largest prison populations in the country, mental illness has been diagnosed in about 8,400 of the 63,000 inmates, according to the State Office of Mental Health. The number of inmates has decreased significantly in the last few years, but Mr. Gangi said the number of mentally ill prisoners was rising, possibly because the condition is being more accurately diagnosed.

Under the agreement, mentally ill prisoners sent to solitary confinement would be entitled to leave their cells for therapy and treatment for two to four hours daily. Their placement in solitary confinement would have to be preceded by extensive reviews, all prisoners entering the system would be screened for mental illness, and the state would be required to provide some mentally ill prisoners with alternative residential housing.

State officials said that because of both the agreement and their own budgetary priorities, they had set aside an additional $9 million in the 2007-8 fiscal year for programs within existing prisons and new or renovated facilities to accommodate mentally ill inmates, a total of $57.5 million dedicated to mentally ill inmates.

The agreement also stipulates that New York prisons, which local and national advocates say are unique in using restricted diets to punish prisoners already in segregation, cannot use the cabbage-and-loaf punishment for more than seven days with mentally ill prisoners without "exceptional circumstances."

Lawyers who brought the suit and national prisoner rights advocates said the New York settlement was unique in covering all mentally ill prisoners, from the time they enter the system until they leave, whereas some states have merely stopped sending prisoners with major mental illnesses to prisons with especially harsh conditions.

"The proof of the pudding is in the eating," said David C. Fathi, senior staff counsel with the American Civil Liberties Union’s national prison project, who has handled several cases around the country regarding the treatment of mentally ill inmates. "We will have to see how this is implemented. But on paper, it is very significant, a victory and a step forward."

He added, "Now we can point to New York and say, if New York can do it, why can’t you do it?"

Sunday, April 22, 2007

State leaders ask if the prisons are really the best places for such juveniles.

By LISA SANDBERGCopyright 2007 Houston Chronicle Austin Bureau

AUSTIN — Texas Youth Commission staff have to watch for more than just poor behavior when looking after Zachariah Tarver — they have to ensure he's not hanging himself, slicing his veins, writing on the walls with his blood or drinking cleaning fluid.

It's not easy. Tarver has done these things before, threatening or attempting suicide at least a half-dozen times in the 10 days after he was plucked from a psychiatric hospital and sent to TYC late last year, agency records indicate.

The youth, now 18 and confined to TYC's Corsicana Residential Treatment Center, has spent virtually every day since his arrival on suicide watch. He hallucinates, and he responds to questions from doctors with a smile, no matter what is asked of him, according to the records, which were provided by his family.

Psychiatrists hired by TYC diagnosed him with major depression, bipolar and schizoaffective disorders and drug dependence.

Now, as state leaders work to overhaul TYC, many are asking the question: Are juvenile prisons the best settings for mentally ill youths like Tarver?

He had two brushes with the law, including taking his father's car without permission, before being sentenced to TYC last year for driving without a license and violating curfew.

"I personally don't think that the mentally ill should be treated like law violators if their medical problems are causing the behavior," said Sen. John Whitmire, D-Houston, who co-chairs the joint legislative committee investigating the myriad problems that beset the agency.

Whitmire said confining juveniles who are mentally ill should be a last resort.

In the wake of a scandal involving reported sexual or physical abuse of inmates by guards at several TYC facilities, lawmakers are promising to substantially reduce the system's offender population and make it a place for seriously delinquent youths whose behaviors aren't caused by illnesses.

But they're also grappling with issues of public safety since some mentally ill inmates have committed violent offenses.

A bill making its way through the Legislature would keep those with misdemeanor convictions out of the TYC system and would provide local communities more resources to treat most mentally disturbed youths in community-based settings closer to home.

The task is daunting, given the number of youths with mental health issues who wind up in TYC.

The agency decided mental health services were required for nearly 38 percent of the 2,700 youths it received in 2005.

Leaving in worse condition

Until she resigned under pressure last week, Corrine Alvarez-Sanders, TYC's assistant deputy executive director for rehabilitative services, had worked with young inmates for 15 years and said too many who are mentally ill don't get appropriate treatment and leave in worse condition than when they arrived.

Secured lockups are appropriate for some mentally ill offenders with violent tendencies, but every one of those would be better served in smaller residential treatment centers, she said.

"I don't want to say that all of our facilities are producing outcomes that are worse. But what's clear to us is the interventions don't match the specialized needs that are present," Alvarez-Sanders said.

She's seen those with borderline intelligence disciplined for failing to complete written assignments they were incapable of doing.

"I'm not going to minimize the fact that we have kids in our care that are confined for excessive lengths of time," she said.

Juveniles entering TYC spend several weeks at the Marlin Orientation and Assessment Unit, 25 miles east of Waco, undergoing a battery of psychological, emotional, vocational and chemical dependency tests.

Those deemed suffering from severe mental disorders are assigned to either the Corsicana Residential Treatment Center or the Crockett State School, which have specialized psychiatric care, higher staff-to-offender ratios and rehabilitative programs tailored to their needs, Alverez-Sanders said.

Marquieth Jackson has spent 3 1/2 years at TYC but only one month at Corsicana, where no one could handle him, said the attorney representing his Houston family. Jackson was sent to a facility in Beaumont that specializes in drug treatment.

No one could dispute that Jackson suffered from severe emotional and behavioral problems when he was sent to TYC at 12 for violating probation by breaking a window, one of his numerous encounters with police.

Before he ever stepped foot in TYC, he'd been diagnosed as being bipolar and depressed, with schizoaffective and attention deficit hyperactivity disorders, according to TYC records provided by his mother, Tarsha.

By age 4, he'd been kicked out of day care for aggressive behavior. At 10, he assaulted a teacher.

He was committed twice to psychiatric hospitals and received intensive counseling from the Mental Health and Mental Retardation Authority of Harris County.

Incapable of following rules

Tarsha Jackson said her son has received virtually no mental health treatment or medicine since arriving at TYC. (The agency cannot discuss specific cases.)

Like most offenders, Marquieth came into the system with a nine-month minimum sentence. His mother said he's too mentally ill to follow TYC rules. "I tell them, 'You've had him since he was 12. If he hasn't been able to work your program in 42 months, what are you going to do? Keep him until he's 42?' "

In a sign that things may indeed be changing, Tarsha Jackson received word recently that her son, who's now 15, would soon be discharged on a mental health release.

She's relieved but insists she's realistic about the difficulties ahead.

Texas Juvenile Probation Commission statistics indicate 38 percent of TYC inmates arriving in 2005 suffered from mental health disorders, although the agency indicated the number could be as high as 50 percent. Of those deemed mentally impaired by the agency:• 11 percent: Confined for nonviolent misdemeanors;• 17 percent: Confined for violent felonies;• 20 percent: Confined for nonviolent felonies, such as car theft or burglary;• 3 percent: Confined for violent misdemeanors, such as noninjury assault

Saturday, April 21, 2007

Q: Just when we were so preoccupied with the fear of terrorism, now comes news of the deadly Virginia Tech shooting. It looks like school violence is back in the news. What causes someone to commit mass murder? What are the effects on individuals and communities? How can law enforcement and the general public best prevent, respond to, and recover from episodes of school violence?

A: School violence is not really back in the news because it never left. Most recently eclipsed by the war on terror, incidents like Virginia Tech – as with Littleton, Columbine, and others – remind us that most killers of Americans are still our own citizens and that many of these murders take place where we expect them least, our schools. This column will provide some insight into the psychology of this modern form of mass murder and provide some practical recommendations for preventing, responding to, and recovering from school violence.

Demographics of School Violence

The good news is that youth violence as a whole has been decreasing in frequency since the 1970’s. However, during the same period, the severity of juvenile violence has dramatically increased, with a greater number of homicides and involving more potent weapons. In addition, students are committing violence at increasingly younger ages. According to National School Safety Center, almost 3 million crimes are committed on or near a school campus each year, accounting for 11 percent of all reported crimes in the United States.

In this context, high-profile multiple murders on school campuses, horrific though they may be, are still relatively low-frequency events. Much more common are the everyday instances of bullying, harassment, and nonlethal violence that occur on school campuses across the nation and the world. These, too, can be psychologically traumatizing and may set the stage for episodes of explosive violence.

School Victimization

The kinds of intimidation and harassment that would get an employee fired at almost any job is routinely tolerated by school authorities when it occurs between students. In virtually every case of school violence studied, the perpetrators had been harassed or persecuted in some way by other students and their efforts to have their cases resolved by school authorities were rebuffed or ignored. Of course, a far greater number of bullied students suffer in silence without seeking to redress their injustice with a greater atrocity.

Peer victimization is the experience of being a target of the aggressive behavior of other students. Indirect aggression is carried out through a third party or in some way that conceals the identity of the aggressor. Relational aggression is behavior which damages peer relationships and acceptance within the social group. In verbal victimization, the student’s status is attacked or threatened with words and this can be exceedingly vicious and damaging to a student’s psyche and self-image.

Studies have shown the effects of school victimization to include lowered self-esteem, increased loneliness and isolation, anxiety and panic attacks, depression and suicidal thoughts, psychosomatic symptoms, and posttraumatic stress disorder. Victimized children miss more days from school, suffer impaired academic performance, and make more trips to the doctor.

Only rarely, do disturbed, desperate students resort to violence but, when they do, it often highlights systemic problems that have occurred for a long time – a strong parallel with workplace violence.

School Violence Perpetrators

For all the media attention given to school violence, very little empirical work has been done in the psychology of this kind of youthful mass murder. Accordingly, much of what we know about school violence perpetrators has been extrapolated from studies of other types of mass murder, especially older perpetrators of workplace violence, who have been studied for several decades, as opposed to school shootings, which are a more recent phenomenon.

The cycle of violence typically begins when the student undergoes an event or series of events that he perceives as the "last straw" in a cumulative series of humiliations. Based on his predisposing personality and psychological dynamics, his reaction will consist of some combination of persecutory ideation, projection of blame, and violent revenge fantasies. As thoughts and emotions stew, the student isolates himself from the input of others and enters a mode of self-protection and self-justification in which a violent act may come to be perceived as "the only way out." The actual commando-style mission may be executed impulsively and all at once, or it may undergo numerous revisions and months of planning. The violent act itself may be carried out alone or with the collaboration of like-minded compatriots. In most cases, the episodes end with the death of the perpetrator(s), either by their own hand or by responding law enforcement authorities.

Preventing School Violence

Academic administrators who remain unmoved by the human costs of school violence might want to consider the potential legal and financial liabilities. In Stoneking v. Bradford Area School District, 1988, the court found that, if a school is aware of dangerous and unlawful activities on its premises and takes insufficient action to address them, it may be found liable under the 14th amendment. School officials may be protected from liability, however, if they can demonstrate due diligence in their prevention of crime on campus.

Accordingly, the following recommendations are adapted from a large body of work in the area of workplace violence that can be productively applied to the academic setting. Law enforcement officials, in particular, should be aware of these concepts because local police departments are typically the main agencies contacted by schools for advice on violence prevention programs, and they are almost always the first to be called when a crisis erupts.

Clear Policies. Schools should have clear, strong, consistent, written policies against bullying, intimidation, and harassment. They should have effective security programs, a standardized, confidential, and user-friendly reporting system, a supportive faculty, open channels of communication, and training in verbal negotiation and conflict resolution skills. Schools must have a clearly understood policy of zero tolerance for violence. This should be contextualized as a safety issue, the same as with rules about fire prevention or disaster drills. Plans should be in place that specify how threats are reported and to whom, as well as a protocol for investigating threats.

Safe Discipline. As in the workplace, many acts of violence relate to the perpetrator feeling he was treated unfairly by the administration; some of this relates to confusion over the very zero-tolerance policy cited above. Schools should develop an individualized disciplinary program that strikes a balance between a too heavy-handed approach that might discourage reporting and participation, and a too lax approach that gives the impression of ambivalence and lack of control. Discipline should occur in stages, with a clear policy and rationale for each action taken. School officials should not be afraid to "pull rank" where student safety is concerned.

Safe Suspension or Expulsion. If it comes to that, suspension or expulsion from school can be clear and firm, without being inhumane. This should include a systematic process of documentation of the precise behaviors and rule violations that have necessitated these actions. The student and his family should be treated with reasonable respect, but should understand that the action is final and will be backed up. The student should be informed of any counseling or other services offered by the school for the transition period. For behaviors that constitute criminal acts, school officials should report these to local law enforcement or their own school police if they have them.

Responding to School Violence

Sometimes, despite the best efforts at prevention, a dangerous situation begins to brew and a violent incident becomes a distinct possibility. Or the incident just erupts explosively and personnel have to respond immediately. In either case, the effectiveness of the response will be determined by how thorough the pre-incident planning and training have been.

Warning Signs of Impending Violence. It’s always best for school officials to know their individual students, but generic warning signs include deterioration or changes in dress, speech, facial expression, increased agitation, anxiety, isolation and/or depression, evidence of substance use, or preoccupation with violent events in the media. Almost always, the student’s peers will know something is up way before parents or teachers, which is why a safe and confidential reporting system is so important.

Defusing Violence. Planning and training for defusing potentially violent episodes should be developed, put in place, and reviewed periodically. Elements of such a protocol include initial actions to take when danger begins to escalate, codes and signals for summoning help, chain of command for handling emergencies, appropriate use of verbal control strategies and body language, scene control and bystander containment, tactics for dealing with weapons, and hostage negotiation procedures.

Recovering From School Violence

The crisis is not over when the police and TV crews leave. Students or faculty may have been killed, others wounded, some held hostage, and many psychologically traumatized. Schools should proactively establish policies, procedures, and training for responding to the aftermath of a violent incident, and the plan should include the following elements.

Law Enforcement, Physical Security, and Cleanup. A school representative should be designated to work with local, regional, and/or federal law enforcement. Within the limits of safety, the crime scene should be kept intact until investigators have gone over the area. There should be someone assigned to immediately check, protect, or restore the integrity of the school’s data systems, computers, and files. Physical cleanup of the area, pending approval from law enforcement, should be conducted in as respectful a manner as possible.

Mental Health Mobilization. This includes a prearranged plan for school representatives to contact local mental health professionals immediately, arrange for the clinicians to meet first with school officials for updates and briefings, conduct crisis counseling with affected students, faculty, and families, and arrange follow-up schedules for mental health clinicians to return for psychological services as needed.

Student and Family Interventions. Another designated school official should notify the victims’ families of the incident and be ready to offer them immediate support, counseling, and referral services. The school should arrange time off for grieving and traumatized students and faculty. After the initial stages of the incident have passed, mental health clinicians should help students and school officials find ways of memorializing the victims.

Media and Public Relations. A media spokesperson or public information official should be designated to brief the media and shepherd them away from grieving students, family members, and faculty. School officials should cooperate with law enforcement authorities as to the timing and content of news releases.

Legal Issues and Post-Incident Investigations. These measures include notifying the school’s legal counsel who should be asked to respond to the scene, if necessary. Investigatory questions include the nature of the perpetrator(s), their relationship to fellow students and faculty, history of disciplinary action or suspension, specific circumstances or institutional stressors that may have led to the incident, the role of mental illness or substance abuse, any warning signs that should have been heeded, and a thorough review of the school’s overall security, threat assessment, and critical incident response protocols.

In summary, if any good can come out of a school violence episode, it will be in the form of improved policies and procedures that adopt a best-practices model to the prevention, response, and recovery to and from any kind of institutional mass violence. In these efforts, law enforcement agencies have a vital role to play.

Laurence Miller, PhD is a clinical and forensic psychologist and law enforcement educator and trainer based in Boca Raton, Florida. Dr. Miller is the police psychologist for the West Palm Beach Police Department, a forensic psychological examiner for the Palm Beach County Court, and a consulting psychologist with several regional and national law enforcement agencies. Dr. Miller is an instructor at the Criminal Justice Institute of Palm Beach County and at Florida Atlantic University, and conducts continuing education and training seminars around the country. He is the author of numerous professional and popular print and online publications pertaining to the brain, behavior, health, law enforcement, criminal justice, and organizational psychology. His latest books are Practical Police Psychology: Stress Management and Crisis Intervention for Law Enforcement (Charles C Thomas, 2006) and the forthcoming Mental Toughness Training for Law Enforcement and Street Psychology 101 (Looseleaf Law Publications). Dr. Miller can be contacted at (561) 392-8881 or online at docmilphd@aol.com.

Disclaimer: This article is for educational purposes only and is not intended to provide specific clinical or legal advice.

NEW YORK -- Across America, college counseling centers are strained by rising numbers of mentally ill students and surging demand for mental health services - a challenging trend as campus officials try to identify potential threats like the unstable Virginia Tech gunman.

And even when serious emotional problems are detected, university officials often feel constrained in how they respond due to an array of laws and policies protecting students' rights and privacy.

"The number of people coming to colleges who've had psychiatric treatment has increased tremendously," said Dr. Gerald Kay, a psychiatry professor at Wright State University and chair of the American Psychiatric Association committee on college mental health.

"Now they're able to come to college - that would not have been the case earlier," Kay said. "You've got a very large number of people who may have some vulnerabilities. It has stressed the availability of resources."

Reasons for the surge include the Americans with Disabilities Act, which gives mentally ill students the right to be at college, and increasingly sophisticated medications which enable them to function better than in the past.

Recent surveys and studies underscore the scope of the increase.

A survey last year by the American College Health Association found that 8.5 percent of students had seriously considered suicide, and 15 percent were diagnosed for depression, up from 10 percent in 2000. The Anxiety Disorders Association of America found that 13 percent of students at major universities and 25 percent at liberal arts colleges are using campus mental health services.

Dr. Chris Flynn, director of Virginia Tech's counseling center, has declined to discuss details of gunman Cho Seung-Hui's case, but said the center's staff - which includes a psychiatrist and 11 psychologists - treats about 2,000 students per school year.

In December 2005, a magistrate ordered Cho to undergo an evaluation at a private psychiatric hospital after two women complained about annoying calls from him, and an acquaintance reported he might be suicidal. An initial evaluation found probable cause that Cho was a danger to himself or others as a result of mental illness, but court papers indicate he was free to leave the hospital within days - a step allowed only if hospital officials judged him no longer a danger.

"We have to provide services to students with mental illness - it's not grounds to exclude them from our property," Flynn said. "We cannot discriminate against the mentally ill, nor do we want to."

He said the type of complaints lodged against Cho by the two women are a common and challenging phenomenon on campuses nationwide.

"It is very difficult to predict when what someone perceives as stalking is stalking, and then how it might translate into violence later," Flynn said. "Clearly, if anyone had any warning about a violent incident, people would have stepped in and acted."

Psychologist Sherry Benton, assistant director of counseling services at Kansas State University, has conducted research concluding that students' mental health problems are more complex and severe than 20 years ago.

"We're well aware that problems are getting worse, but what hasn't happened is increasing funding for mental health services," she said. "Most centers are now overwhelmed. Business has gone up and up, but budgets have remained the same or been cut, and that's a huge problem."

One factor, Benton said, is that mental health services are usually not among the categories assessed during colleges' periodic accreditation reviews. If schools needed good services to remain accredited, they might invest more, she said.

Benton views the rising demand for campus mental health services as a good news-bad news development.

"We do get a lot more students into college who have mental illness but are no problem whatsoever," she said. "They do need support and use medication; they go on to lead full, productive lives."

On the downside, she and her colleagues see stress levels among students far higher than a generation ago due to increased workloads and financial strains, often coupled with lack of healthy lifestyles.

Complicating the overall picture is a web of laws and policies that limit the options for worried staff members. Troubled students generally can't be forced to obtain treatment, and privacy laws may limit sharing information about them, even to the extent that some parents have sued schools - including the Massachusetts Institute of Technology and the Oregon Institute of Technology - for not advising them of their children's serious disorders.

Nonetheless, officials on many campuses have set up committees to pool information about students with emotional or behavioral problems so patterns can be detected in what might otherwise be seen as isolated incidents. The trick, officials say, is to find the proper balance between respecting a student's rights and protecting the university.

"That's the tightrope administrators have to walk," said Wright State's Gerald Kay.

"The issue in most instances is how do you bring these people into some sort of treatment."

Benton said any student who issues threats should be dealt with forcefully, regardless of privacy guidelines.

"Safety trumps confidentiality every time," she said. "If someone is a danger to themselves or others, then confidentiality is out the window and you notify who you need to notify to ensure the safety of them and those around them."

Peter Lake, a law professor at Stetson University, contends that officials on many campuses have been too deferential to privacy concerns, at the risk of safety at their schools.

"There's a false consciousness of privacy in higher education - as an institution, we don't like to share information," he said.

"Now, you're going to be seeing a greater emphasis on a management team or a safety czar - someone whose job it is to look at students' overall profiles," Lake said. "It's not only a good idea - it's an idea we can't live without."

Thursday, April 19, 2007

The shootings at Virginia Tech exposed a college trend that worries campus mental-health counselors: rising numbers of troubled students who may not be getting the help they need.

Cho Seung-Hui was reported to police and spent time in a psychiatric hospital, Virginia officials said Thursday, but none of that intervention prevented him from killing 32 people and himself this week.

Mental-health officials at several Florida campuses said they face the same budget constraints and privacy considerations that complicated efforts to help Cho, a sullen student who alarmed English instructors with his violent writings.Despite their best efforts, officials said, someone can slip through the cracks.

"We could tell you today the students that keep us awake at night," said Lesley Sacher, director of Thagard Student Health Center at Florida State University.

College counseling centers across the country report not only an upswing in the number of patients who visit the clinics, but also a surge in the number of freshman students with mental-health problems.

A 2006 National Survey for Counseling Center Directors done by the University of Pittsburgh shows that 92 percent of counseling-center directors nationwide reported concerns about an increased number of students with serious problems.

They also reported jumps in the numbers of students who hurt themselves and those who sought crisis counseling during the past two years.

Clinic directors in Florida say that often the best they can do is screen students carefully and stay alert.

For example, Sacher said mental-health professionals see many students who saw psychiatrists in high school, who take medication to cope and need additional care in college. They are "extra-bright, unbelievably talented, but extraordinarily fragile," she said.

Waits can take weeksBut getting help for them can be difficult.At FSU, students wait three to five weeks to see Sacher's two psychiatrists. Three years ago, the center, which serves FSU's 40,000 students, didn't have any. Last fall, the University of Florida's director of student affairs pleaded with the state for more money for its clinics.

The University of Central Florida has one counselor for every 3,250 students. Industry standards call for one for every 1,000 to 1,500 people. Like officials at the other universities, David L. Wallace, the UCF counseling center's director, said he could double his staff and "it would not be out of line."His counselors deal with emergencies and problems that can be handled quickly, referring students with chronic and more-intense issues to off-campus facilities. They do not have much time for prevention and training programs that might, for example, help students recognize signs of depression in classmates.

"These are the things that so often get put on the back burners," Wallace said. "There is strong recognition there is need for more help, and sometimes the funding is just not available."Campus clinics only see those students who want help, of course.

How to reach the rest, including students such as Cho, is much harder.

In November and December 2005, two women complained to police at Virginia Tech that they had received "annoying" calls and computer messages from Cho, police said.

After the second complaint, the university obtained a temporary detention order and took Cho away for psychiatric evaluation because an acquaintance reported he might be suicidal, authorities said.

About the same time, Cho was referred to the university's counseling service after an English instructor expressed alarm at his writings, police said. It is not clear whether he followed through with treatment.

'It's a difficult thing'Counselors, teachers and administrators in Florida said they walk a fine line not only in picking out who might be a threat, but also in what to do about it.

Thomas Krise, chairman of UCF's English department, said he thinks his Virginia colleagues tried to help Cho.

"It's a difficult thing," Krise said. "English professors are very well-trained, but we're not trained as counselors or psychiatrists. . . . It doesn't sound to me like they missed something.

"The screenplays and assignments that alarmed classmates and instructors were filled with violence, profanity and other vulgarities -- not much different at first glance from video games and gore films on the market today.

Students often write that way, and creativity doesn't indicate mental illness, educators said.

"Stephen King is not chopping up people and putting them in the basement" just because his writing depicts horrific acts, said Stephen Schlow, chairman of UCF's film department.

But since Monday's massacre, the issue of disturbed students has been a frequent topic of conversation.

"That's almost all we've talked about in my office," Schlow said."My guess is that if it were truly disturbed, we would notice it," he added. "That doesn't mean if we said the person is truly disturbed, we would get any more action than they got in Virginia."

Schools can be stymied

Universities have limited options when a student refuses counseling. They can't force an adult to seek care and can't legally contact parents without permission. Most won't expel a student for refusing treatment.

What administrators often do is focus on a behavior. If a student won't stop cutting himself, making suicide threats or stalking others, Florida schools often step in and recommend he take a break to recuperate, said Wayne Griffin, director of UF's Counseling Center.

Peter Lake, a law professor at Stetson University and co-author of The Rights and Responsibilities of the Modern University, said universities need better systems for reporting and intervening in such problems.

A dean may not know faculty has talked to a distressed student or that the student faced trouble with police. Campuses need a strong central system and policies in place to get help quickly, including those that permit professionals to warn the community if a patient poses a danger.Officials at FSU and UF say they have similar systems in place. But after Virginia Tech, they say, every higher-education institution will be reviewing its policies to ensure they catch distressed students before disaster happens.

"This will change higher ed forever," Lake said.

Erika Hobbs can be reached at ehobbs@orlandosentinel.com or 407-420-6226.Leslie Postal can be reached at lpostal@orlandosentinel.com or 407-420-5273.Information from The Associated Press also was used.

ALBANY -- Thousands of severely mentally ill inmates in New York's prisons will receive more treatment as part of a landmark settlement in a federal lawsuit brought by prisoner advocates.

The agreement is expected to be signed April 27 by a federal judge and the parties involved.

It was negotiated after five years of litigation and two weeks of a nonjury trial before U.S. District Judge Gerard E. Lynch in New York City.

"This greatly expands the mental health services available within the prison system," said Cliff Zucker, executive director of Disability Advocates, a not-for-profit group in Albany that was the plaintiff.

About 8,000 of the state's 63,000 inmates have been diagnosed with serious mental illness. Hundreds are kept in solitary confinement and studies have shown they are far more likely to commit suicide or injure themselves.

Along with adding staff, resources and new beds for mentally ill inmates, the settlement bans some seemingly barbaric prison practices, such as:

Stripping naked mentally inmates suffering an acute psychotic episode, segregating them in a Plexiglas-walled cubicle and leaving them with nothing but a thin pad on a cement floor.

The use of punitive "restricted diets," a loaf made from bread and cabbage, for punishment.

It also adds two to four hours of therapy outside the cell for mentally ill prisoners currently locked down in 23-hour solitary confinement.

Dan Odell, a spokesman for the state Office of Mental Health, which was a defendant in the lawsuit along with the state Department of Correctional Services, expressed satisfaction at the resolution of the case. He said details have not yet been worked out, but the settlement will require more mental health professionals and other resources to the prison system.

In the recently adopted state budget, Gov. Eliot Spitzer called for an additional $60 million over three years for services for mentally ill inmates. That includes $50 million in capital construction costs, $2 million for Office of Mental Health staffing and $2 million for Correctional Services staffing this year, growing to $9 million a year in 2009.

Construction money will be used to build facilities for 405 mentally ill prisoners, with 305 transitional intermediate care program beds for those with mental illnesses and a 100-bed residential mental health unit for severely mentally ill inmates who otherwise would be placed in solitary confinement. Also, all new inmates will be carefully screened by professionals for mental illness for the first time.

Spitzer spokeswoman Christine Pritchard said: "Through a considerable investment in state resources in the budget this year, the Spitzer administration has committed to providing significant improvements to the services and housing available for mentally ill inmates."

Sarah Kerr, staff attorney for Prisoners' Rights Project of the Legal Aid Society in New York City, said: "We believe there's real commitment now in the leadership of the state agencies that will result in true reform for mentally ill prisoners."

Kerr, who spent five years working on the lawsuit, and attorneys with Disability Advocates were joined by attorneys with Prisoners' Legal Services of New York and pro bono lawyers with Davis Polk & Wardwell, a New York City law firm.

Also Tuesday, advocates lobbied at the Capitol for passage of a law to end all solitary confinement for mentally ill inmates.

"We're moving full-speed ahead," said Harvey Rosenthal, an organizer of the event and head of the New York Association for Psychiatric Rehabilitation Services.

By themselvesIn 2002, the Times Union published "The New Asylums," a special report by Paul Grondahl that looked at New York state's use of 23-hour solitary confinement as a disciplinary measure for inmates. Read the archived series at timesunion.com/specialreports/newasylums

A new report states that over half the nation’s jail and prison inmates suffer from mental health disorders.

The study, released by the US Department of Justice’s research arm, confirms what wardens, inmates and corrections officers already know – that large numbers of convicts routinely exhibit symptoms of mania, anxiety, depression or psychotic disorders.

The report’s findings are based on a representative survey of more than 25,000 prisoners nationwide. The study showed that mental health problems were associated with an inmate’s violence and prior convictions. Those state prisoners with mental disorders were more likely to have at least three prior incarcerations and to have broken prison rules.

Mentally ill inmates were also twice as likely to have been injured in a prison fight, and substantially more likely to have been abused as a child and homeless in the year before their arrest. Three out of four were dependent on drugs and alcohol, with 37% saying they used drugs at the time of their crime.

Experts called the study disturbing. They said it illustrates a direct relationship between community health care gaps and the large numbers of mentally ill people who wind up in the criminal justice system.

Bill Emmet, of the Campaign for Mental Health Reform, said, "If one out of three people incarcerated in this country are receiving mental health treatment, it shows that there is something very wrong with the way services are delivered in the community. People need services before they do something that might result in their incarceration."

Furthermore, the study found that:Female inmates had higher rates of mental illness than men – with 73% of females in state prisons reporting symptoms, compared to 55% of all males.

The prevalence of mental illness in prisons varied by race, with 62% of white inmates suffering from problems, compared to 55% of blacks and 46% of Hispanics.

Over half of mentally ill inmates had a family member who was incarcerated, and about 19% lived in foster care at some point while growing up; twice the percentage of inmates without mental health problems.

Wednesday, April 18, 2007

A firearm in the hands of the wrong person can be deadly. The presidency in the hands of the wrong person can also be deadly. Air travel safety regulations have convinced some of us that a finger-nail clipper in the hands of the wrong person can precipitate a terrorist attack. From these examples, it doesn't make sense to ban either the presidency or manicure devices.

What makes much more sense is to focus on the issues that prompt a maniac to use a firearm to kill innocent people; a president to kill innocent people; or a terrorist to kill people. When it comes to the latter, those of us on the progressive side of the nation haven't spent much time blaming the explosive devices or the box cutters, but rather the policies which have fostered so much resentment against the United States. We all know the list and it has nothing to do with hating us for our freedom.

So what causes a maniac to murder 30 people in cold blood? It can't possibly be about the 9mm handguns, in the same way terrorism isn't about access to beverage containers.

Yeah, I'm one of those progressives who has long since conceded the gun debate. It's not because of the gun lobby's simplistic talking points, it's not because of the hunters who think it's most excellent to kill innocent animals, and it's definitely not due to a lack of thought about the issue.

It's primarily about focus. Who or what is really to blame for the shameful level of gun violence in America?

The focus has to be aimed point-blank at the cold, brutal reality that there exists a serious inability to cope with American pop, economic and social pressures; a criminal lack of understanding of mental and physical health issues; and the problem solving examples instilled upon us by our elected leaders in a time when visual and printed access to information is at an all time high. These are just some of the elements at play, and they each carry a significant amount of blame. Not the guns.

President Bush himself has told us that shooting without negotiation is the only answer. The generation of kids in my daughter's demographic has to struggle in order to recall a time without this preemptive war. The only evidence they possess that indicates reasoning and negotiating with an enemy actually works is what they read about in history books. Their president and vice president have told them that the Speaker of the House shouldn't talk to our enemies because open dialogue is somehow a reward, rather than a rational responsibility.

And irresponsible behavior doesn't end at the front gate of the White House or at the steps of Capitol Hill.

Every day we're bombarded from all sides by marketing that tells us that our bodies aren't ripped enough. Our credit score is too low, but a Visa card is priceless. We need a bigger car. We need more chemically polluted foods, then the diet pills to interdict with the chemicals, then more medications to interdict with the diet pills, then additional meds to give us boners and free-flowing piss when our organs stop functioning from all of the above. We need plastic surgery to feel accepted. We need acceptance in order to be popular on MySpace. We have to redecorate our homes, buy a souped up chopper, eat brick oven pizza with five varieties of cheese and we need to display bumper magnets that prove to the dickhead behind us in traffic that we unequivocally support the troops.

Meanwhile, the divide between the people who can easily purchase all of these items and the people who can barely afford to keep their city water turned on is growing larger and larger, while the middle class is disappearing. It used to be that a guy could work 40 hours a week in a blue collar job and still be able to own a home, send his children to college and take his family on vacation every summer, with a pension waiting for him on the other side.

In every city, as well as a staggering number of suburbs, crime is becoming the only way to keep up with the 21st Century version of the American Dream (now with easier pissing power!).

Besides, aren't our kids supposed to shoot before they talk?

Who should we really be afraid of, anyway? The black kid with the oversized NFL parka or the white man in the suit rationalizing that it's okay if he pollutes the air or pumps our kids with mercury-contaminated vaccinations and high fructose corn syrup until they're fat, diabetic, cancerous globules lumbering diligently from the drive-thru to the waiting list for gastric bypass surgery? Obviously the black kid in the NFL parka is the one to fear because, let's face it, even though it's going to be a painful torturous death, the white man will kill you with snack foods that come in "fun" shapes -- AND he offers a fully stocked biggie-sized menu. (The non-snark answer is that the white man in the suit selling high fructose corn syrup is the one to fear, given the choice.)

Despite all of it -- coupled with gun ownership -- most of us don't run around killing people. The answer, they say, is to ignore these societal factors if you choose to. Be your own person! An individual! You know, like they teach in schools where everyone is forced to dress the same and where the creative arts are being downsized.

Yet in an era when we're being marketed to and categorized without even knowing it, how can we possibly avoid the perils of the modern American Dream (now featuring Crazy Bread!)? Combine this with record foreclosures, record bankruptcies and a health care system that, if you can afford it in the first place, will provide you with something for your Restless Leg Syndrome while refusing to cover your psyche meds and therapy sessions.

Millions of American citizens with an array of mental illnesses are walking around without the means to be diagnosed in the first place, much less to be treated properly -- and a growing number of those Americans are Iraq veterans. Health insurance carriers won't insure you if you have a prior history of anything from basic depression to full blown schizophrenia (2 million diagnosed Americans with schizophrenic disorders and counting), even though many mental illnesses erase the ability to discern between a first-person-shooter video game and a group of students on a college campus. Mental illness is the difference between keeping a handgun for self defense and using it to liberate human beings from their oppressive world.

Give a person with an untreated and severe mental illness a handgun and a target, and another Virginia Tech massacre waits in the wings. Take away the handgun, and it'd be homemade explosives. Take those away and it'd be poison in the cafeteria food (beyond the legal poisons already mixed in). What else can be taken away? Basic freedoms and liberties, maybe? Video games?

The key, as best I see it, is to leave most of the guns alone (and the video games, Senator Clinton) and provide real health insurance for everyone, then to begin the slow process of rebuilding a viable middle class in America.

If the NRA, among others, truly wants to win this debate, it should dedicate a large percentage of its lobbying resources to promoting guaranteed affordable (free is better), comprehensive health care coverage for every American. Additionally, if you want to keep your firearm, tell your elected representatives that tax breaks for the wealthiest Americans should be rolled back in favor of serious tax breaks for the middle class. This will begin to close the divide between crime and earning an honest living. Proper health care will begin to tackle the rate of untreated mental illnesses which, at the very least, will reduce the numbers of gun crimes by those of us who aren't able to handle or fully process the torque of modern American reality.

UPDATE: Wednesday, 4/18/07. Just wanted to add something here. I am most definitely not blaming the VT massacre on the president. You're welcome to believe that, but you'd be terribly wrong. All I have suggested is that the president's shoot-first preemptive approach isn't setting the proper example for an entire generation of Americans.

FROM THE COMMENTS: Virigina Tech student "Tim" has made some outstanding points:It is not about guns. The deaths of over 30 students and faculty of Virginia Tech should not be blamed on two guns. Guns do not kill people, people kill. We choose the debate of gun control at this time, because there are no other times in which it is as appropriate. I question the thought process of those who state that this would have been less of a problem if more people carried guns - if only one of the students sitting in one of those classrooms could have reached into his or her bag to pull out a handgun to end the situation sooner.

We give names to people like the shooter at Virginia Tech - Monsters, Maniacs, Evil-doers. Before they were given those names, we gave them the names of son, neighbor, friend, and fellow student. In order to explain why one of us would do something like this, we must first expel the person from the village and label him an outsider.

When people talk of the need to bear arms in order for protection, they speak of incidents of unknown assailants in the home or down a dark alley. They speak of the hidden maniacs and monsters amongst us. They never speak of the person sitting next to them at work, at home, or in the classroom that has been emotionally been pushed beyond reason, because then it becomes a son, neighbor, friend, fellow student, or yourself.

In a society of concealed handguns, the dark alleys do not concern me as much as the emotions of myself and my fellow man who in the moments of irrationality can cause unknown horror.TimVirginia Tech Student

cross-posted from Huffingtonpost.comAuthors Website: http://www.campchaos.comAuthors Bio: Bob Cesca is a writer, director, and producer as well as the founder of Camp Chaos Entertainment, an animation studio based near Philadelphia. He's written and produced literally hundreds of animated shorts as well as music videos for Iron Maiden, Meat Loaf, Everclear, Yes and Motley Crue. Just after 9/11, Bob produced and directed an independent feature film titled The War Effort: a mockumentary satirizing the nation's knee-jerk patriotism which arose following 9/11. He's also the creator of the animated sketch show "ILL-ustrated" which aired for two seasons on VH1and MTV2. Bob grew up in Northern Virginia and graduated from Kutztown University with a degree in Political Science. He's the editor of the RealityBasedNation.com blog.

Mary Winkler’s psychologist took the stand Tuesday, making disturbing testimony.

The psychologist testified that Mathew Winkler would force Mary to perform explicit sexual acts against her will.

Dr. Lynn Zager said, "She said he did not stop and that raised concerns that perhaps it would hurt her, hurt her body. He made some comment that she could have surgery to fix it."

Dr. Zager also testified that Mathew tried to stop the couple’s then one-year-old daughter from crying by covering her face. D

r. Zager said, "Putting his hands over her nose and the baby’s mouth to keep her from crying and she described how Mathew had done that their other children when they were babies."

Mary's adopted sister Tabitha Freeman said the couple would often plan trips to see them, but cancel at the last minute.

She said, "We were upset that we had not been seeing her, and we told Matt about it, and he called the children together and told us that Mary wasn't our sister anymore and that we should never expect her to be there for us ever again."

The psychologist also testified that Mary Winkler suffered from mild depression and post-traumatic stress disorder from her childhood.

She said Mary's mental illness got worse with the abuse.

The psychologist said Mary could not have planned or intended to commit a crime because of the mental illness.

Virginia Tech gunman Cho Seung-hui was a moody loner who took antidepressants and wrote gory fiction, news reports say. But nobody could have predicted from this that he would commit violent acts, experts tell WebMD.

Officials have identified Cho, 23, as the gunman who Monday shot and killed 32 people on the Virginia Tech campus.

"When a tragedy like this happens, we want to know how to defend ourselves and our families. We are very eager to see this as a gross aberration that might have identifiable warning signs," Jeff Victoroff, M.D., tells WebMD.

But that simply isn't the case, says Victoroff, an associate professor at the University of Southern California and an expert on human aggression and the neurobiology of violence. People like Cho have, throughout history, appeared without warning in every human culture.

"It is true that people like Mr. Cho and the Columbine shooters exhibited some aberrant behaviors that, with 20-20 hindsight, might have tipped off sensitive observers," Victoroff says. "But we don't usually attend to those warning signs because they are so common among adolescents. ... We will never be altogether safe from such people."

Unless they have previously acted violently or threatened violence, there's simply no way to predict whether a person will commit a violent act, says Robert Irvin, M.D., medical director of a long-term residential treatment program that is part of the Bipolar and Psychotic Disorders Program at Harvard's McLean Hospital in Belmont, Mass.

"The greatest predictor of acts of violence is prior acts of violence. Lacking that, we cannot say who will be violent and who will not," Irvin tells WebMD.

"There is no reliable predictor of who or who not to avoid. Because that quiet, lonely person who is not so verbal may be very fearful himself and the least harmful person in the world."

Mental Illness, Antidepressants, and Violence

Could the antidepressants that Cho was said to have been taking made him violent? No, Irvin says.

It's not known whether Cho was taking antidepressants under a doctor's supervision, whether he was taking the medications properly, and whether he was taking some drug other than antidepressants.

"Certainly just being on an antidepressant does not increase your risk of engaging in violence," Irvin says. "Antidepressants causing increased risk of self-harm have been talked about, but there is much more evidence to support that they are effective in treating depression. The risk of self-harm is much greater when patients are left untreated."

Might underlying depression be to blame? Probably not, Irvin says.

"People who are hopeless, who don't experience any joy or happiness, their thoughts are far more likely to tend toward self-harm than harm to anyone else," Irvin says. "If they are moved to violence, they are far and away more frequently the victims."

There is a form of depression — some think it a form of psychosis — which doctors call "major depression with psychotic features."

People with this kind of depression have delusional thinking — such as believing everybody at their workplace is very clearly out to get them, perhaps by putting bugs in their offices in order to control them.

"If you are paranoid, perceiving you are threatened when you are not, you might be prone to violence," Irvin says. "But these are people who, if given a choice, would hurt themselves or flee before acting in an aggressive way toward others."

Victoroff agrees that paranoid individuals are more prone than others to commit violence.

"Someone who has a grossly distorted threat-perception system is more likely to commit violent acts," he says. "Humans respond to threat by flight or by fight. Those predisposed to respond with fight who regard innocent people all around them as terribly threatening to them, will be prone to harm those innocent people."

Even so, Victoroff says, the majority of people suffering paranoia do not commit violent acts, so it's impossible to say whether a particular paranoid man or woman will become violent.

We tend to think that only mentally ill people would commit horrific crimes. But this may be false reassurance, Irvin says.

"One of the reasons we try to understand this aberrant behavior in terms of an illness is that it gives us a sense we can identify these people ahead of time. But just because the act is crazy does not mean the person suffered from a defined psychiatric illness," he says.

"It is an ongoing debate whether these people need to be dealt with in the criminal justice system or the mental health system."That's because there are two basic forms of violence: sudden, impulsive acts of aggression and premeditated violent acts."

Premeditated aggression enters the realm of pathologic sociopathy — and there is no good known treatment for sociopaths," Irvin says.

Cho's Violent Fiction

But shouldn't Cho's violent fiction have sounded an alarm? The Chicago Tribune reports that a creative writing teacher was so disturbed by Cho's writing assignments that she referred him to a counseling center.

The Tribune quotes a fellow student as saying that Cho wrote a play in which a boy violently suffocates his stepfather with a Rice Krispies treat.

Writing students do often write frightening things, says Carol Lee Lorenzo, an author and fiction teacher at Atlanta's Callanwolde Fine Arts Center. Where students cross the line, she says, is when they write about actual experiences. In such cases, she says, she returns the assignment and asks the student to justify the violence in terms of the story they are telling.

In her 20 years of teaching fiction writing, Lorenzo says she's never referred a student for counseling.

"Writers reveal things in fiction that are not autobiographical, but are part of our own deep mysteries we are trying to explore," she says. "This does not mean we take these impulses all the way as our characters do. But we have to explore that, or why would anybody read anything we write?"

Perhaps Lorenzo comes close to the terrible truths behind Cho's crime when she talks about why writers describe violent acts.

"Writers are often scared of what is not spoken. So sometimes writers will work with violent things that are expressive of the deep, dark, unfulfilled emotional experience of their lives," she says. "What scares us is this: What if it does become fulfilled in real life by not being expressed in fiction?"

Perhaps this is what happened to Cho.

"We should be more scared of the potential of the human personality than of meeting a grizzly bear in the woods," Lorenzo says. "We are so capable of violence, and yet we have these wonderful controls. If you don't look down at the deep, rich, dark mysteries inside you, you are an even scarier person because it can jump up on you without warning."

The gunman who carried out the massacre at Virginia Tech was well known to campus authorities as a strange and deeply withdrawn individual who frightened his fellow students, and who was briefly committed to a mental hospital as a potential suicide, it emerged yesterday.

By the time Cho Seung-Hui entered the record books on Monday for killing 32 students and professors in America's deadliest mass shooting, he had a history of bizarre behaviour dating from November 2005.

The campus police became involved after two women complained of stalking by telephone and computer. Cho was also becoming a concern to the English department, which was his main field of study. That same autumn he was withdrawn from a poetry class for taking illicit mobile phone pictures of women classmates.

The stalking complaints, which did not result in charges, led the campus authorities to seek Cho's admission to a mental health hospital on December 5 2005 for his evaluation as a suicide risk.

Under Virginia law university authorities obtained a temporary detention order from a magistrate allowing his referral to an off-campus facility, the campus police chief, Wendell Filchum, told a press conference yesterday.

However, those multiple warning signs did not merit special action by the university when Edward Falco, who taught Cho in his playwright course last autumn, raised fresh concerns about the stubbornly uncommunicative student who seemed obsessed with violence.

Mr Falco discovered his colleagues were familiar with Cho. "He was known. He was known in the English department. He was known in the community," he said.

But Mr Falco was told by his department the matter was under control. "All assured me that they had done everything they knew it was appropriate to do. Given those assurances I kept him in my class under special circumstances."

The head of the English department, Carolyn Rude, maintained there were no specific warnings about Cho when she assumed her post last May. "I only knew vaguely that there had been concern about the student and concern for safety of other students," she said.

But Lucinda Roy, her predecessor, had removed Cho from a poetry class in November 2005 because his behaviour and his writing frightened fellow students, as well as his professor, Nikki Giovanni. "There was something about his anger that made me think it just wasn't someone writing. It was a deeper place where it came from," Ms Roy said. "I just thought, here is someone who doesn't have much to lose."

She notified campus counselling services, the legal department, and the dean of students about Cho. "He seemed incredibly depressed. He really needed help."

She also asked campus police to review the writing sample which had disturbed Ms Giovanni. The police were responsive, but Ms Roy said there was little they could do because Cho had not made direct threats. Instead, it was decided that Ms Roy would step in to help Cho complete the course from which he had been removed. She met him for three individual tutoring sessions, and pressed him to seek counselling. Cho did not speak much and when he did rarely raised his voice above a whisper. He kept sunglasses on indoors.

The campus authorities offered Ms Roy protection for the sessions, which she declined, but she had a colleague nearby with a pre-arranged panic signal.

It was unclear yesterday whether Cho obtained counselling, or how long he spent at the psychiatric hospital - St Albans, in Radford, Virginia. According to Ms Rude, there were no further complaints about his behaviour after the stalking episodes in 2005.

But his bizarre behaviour came to Mr Falco's attention on the first day of class. Asked to briefly introduce himself, Cho got up and walked out. Mr Falco hoped Cho had dropped out. He had not. Under campus rules Mr Falco could not remove him, so he reconciled himself to the student. "I felt that he was a strange student, that he was a troubled student, but he seemed to be making it."

In his written comments on others' work, Cho was not overtly hostile, but his own work was "adolescently violent, with a lot of high school angst and anger", Mr Falco said. One of his plays, which has been posted online, begins with an opening scene of a teenager at breakfast with his stepfather, Richard McBeef. It erupts almost instantly into violent rage, with the boy accusing the older man of killing his father and molesting him. "I hate him. Must kill Dick. Must kill Dick. Dick must die. Kill Dick. Richard McBeef," the boy rants. "You don't think I can kill you, Dick? You don't think I can kill you? Gotcha. Got one eye ... got the other eye."

Mr Falco said: "Periodically you get very violent writing. You get writing that is misogynistic, that is hateful. You have to deal with that. What is lack of craft, and what is a reflection of psychological problems - these are not easy to discern."

Ms Roy is worried that there could be many more deeply troubled students on US campuses. "We are getting more and more students who have very special needs. It is a powder keg. You just know that something is going to explode and every so often it does."

There is universal agreement in the United States that an individual convicted of a capital crime who is mentally incompetent may not be executed. To do so would violate the Constitution's ban on cruel and unusual punishments.

But just how mentally ill does a defendant have to be to trigger that broadly accepted Eighth Amendment prohibition?

That is the question the US Supreme Court takes up on Wednesday in a case involving the often bizarre legal odyssey of Texas death row inmate Scott Panetti.

Mr. Panetti, who has a long history of mental illness, was found guilty of the 1992 double slaying of his wife's parents. He shot them at close range in their kitchen as his wife and his three-year-old daughter watched. He took the child and his wife hostage, but later surrendered and confessed to police.

After being found competent to stand trial, Panetti fired his lawyer and represented himself. For the trial, he donned a Tom Mix-style cowboy outfit complete with boots, bandana, and hat.

He argued an insanity defense, advising the jury that only an insane person could prove insanity. Then he tried to subpoena 200 witnesses to testify on his behalf, including John F. Kennedy, the Pope, and Jesus. As one psychiatrist put it: Mr. Panetti's mind "saddles up and rides off in all directions."

Panetti testified at his own trial. He assumed an alternate personality named "Sarge," who recounted in a barely coherent babble impressionistic details of the killings.

The jury found him guilty, and the next day sentenced him to death.

Panetti, who refuses to take any medication, has become a jailhouse preacher, perpetually studying and quoting his well-worn Bible. His lawyer says he is convinced that his religious devotion is the true reason for his death sentence.

"Mr. Panetti believes that demonic forces, in league with the State of Texas, have orchestrated his execution in a final effort to prevent him from preaching the gospels of Jesus Christ," writes Panetti's lawyer, Keith Hampton of Austin, in his brief to the court. "According to Mr. Panetti, the State of Texas is using the murder of his wife's parents as a pretext to fulfill the devil's plot to silence him."

This is the core of the issue before the Supreme Court: Whether a death row inmate whose delusions prevent him from understanding the connection between his crimes and his imminent execution is mentally competent enough to face the death penalty.

Every judge or jury in Texas that has considered his case has concluded that Panetti has a mental illness but that he is nonetheless mentally competent enough to be executed.

The test in Texas is whether Panetti is aware that he is to be executed and aware of the state's reason for meting out that punishment.

Panetti's lawyer argues that the Texas standard is too low. Rather than mere awareness, the condemned man must be capable of having a rational understanding of the connection between his crime and his punishment, Mr. Hampton says.

"There is a big difference between knowing you are in a room and knowing why you are in a room," says Richard Dieter of the Death Penalty Information Center in Washington.

If Panetti doesn't understand why he is being executed, it undermines one of society's key goals behind the punishment – retribution, Panetti's lawyer says.

Others disagree. "Retribution is not focused on the mind of the offender," says Kent Scheidegger of the Criminal Justice Legal Foundation, in a friend of the court brief. "The focus of retribution is on society as a whole and what makes for a just society."

A just society punishes those who are morally responsible for their crimes, he says. "Panetti knows what he did and knows that he has been sentenced to death for the crime," Mr. Scheidegger writes. "His delusional belief in a conspiracy against him does not negate his moral responsibility for the crime he chose to commit and still knows he committed."

Panetti's lawyer counters that retribution is designed to force the offender to endure suffering proportionate to his crime to pay a debt owed to society. That is why the offender's mental capacity at the time of punishment is crucial to retribution, Hampton says. "The offender must suffer for the right reason before the community can confidently conclude that he is getting his just desserts for his wrongdoing," Hampton writes.

We always want there to be an answer, except there never is. Something like Virginia Tech happens, people want to know why.

Jack Levin, the director of the Brudnick Center on Violence and conflict at Northeastern University in Boston, author of more than two dozen books on murder and criminology summed it up. "We’re still in the dark about where this comes from."He co-wrote "Mass Murder: America’s Growing Menace," in 1985. Since then there have been lots of books about serial killers, lots of brain research and many more mass shootings. There are MRIs and talk about high levels of neurotransmitters like dopamine and plunging levels of serotonin. There’s research into the limbic system, a primitive part of the brain that controls emotions and behavior. New medications have revolutionized psychiatric care for depression, even psychotics.

None of it really touches the psychology of mass murder."In mass shootings, the killer is often killed themselves, so we don’t really have the ability to interview and analyze them — all you can really do is work off their behavior," said Neil Kaye, an assistant professor of psychiatry and human behavior at Thomas Jefferson University in Philadelphia.

"The problem with that is that mass killers do this for multiple reasons, and even when you develop a profile of people at risk, 99 percent of them never go out and do anything bad."

Some of the research tells us the obvious: About 95 percent of mass killers are men, they tend to be loners, they feel alienated. They look normal on the outside and are really, really angry inside.

And yet, there are some minor lessons to be learned from this grotesque taxonomy.

Mass murder — like Monday’s — is starkly different from serial killings, the other type of murder that fascinates and frightens.

Serial killers, forensic psychiatrists say, derive sexual gratification from their killings. The Ted Bundys, the Jeffrey Dahmers, the John Wayne Gacys — they don’t want to be caught. They often enjoy taunting police. The violence is, in its own perverse way, about pleasure.

"Serial killers are more like drug addicts than anything else," Kaye said. "They need to ramp up the excitement each time, they’re getting reinforcement from their acts. They’re running on the dopamine side of the brain. They’re running on highs."

It’s not that way for mass killers — guys who take out a gun and try to kill as many people as possible. They’re not looking for highs — they’re depressed, angry and humiliated. They tend to be rejected in some romantic relationship, or are sexually incompetent, are paranoid, and their resentment builds. They develop shooting fantasies for months or years, stockpiling dreams and ammunition. The event that finally sets them off, Welner says, is usually anticlimactic — an argument, a small personal loss that magnifies a sense of catastrophic failure."But they don’t ‘snap,’ as you so often hear people say," Welner said. "It’s more like a hinge swings open, and all this anger comes out."

They plan everything about the killings, he says, except how to get away."It’s about suicide," Welner said.

"It’s about tying one’s masculinity to destruction."

Psychosis is common among perpetrators of mass shootings as a whole, he says, but less common among shooters who are well organized and therefore kill more victims.

Psychotics hear voices and people from outer space and talking dogs.

Perhaps these sorts of taxonomies are the building blocks of actual knowledge, and someday they will matter.

For now, there are no real answers, no real solace, no real consolation.

Tuesday, April 17, 2007

Flanked by leaders of agencies involved in mental health and fighting crime, Chief Justice R. Fred Lewis announced an effort to help people with psychiatric and drug problems avoid winding up behind bars.

Lewis appointed Judge Steve Leifman of Miami as his special adviser on mental health and criminal justice. He said Leifman will immediately leave the bench and examine police and court procedures, as well as policies and practices in executive agencies affecting the mentally ill, the homeless and those with drug dependencies.

''When I became a judge, I had no idea that I was becoming the gatekeeper to the largest psychiatric facility in Florida - that is, the Miami-Dade County jail,'' Leifman said. ''Every day our jails, our courts and law-enforcement agencies are witnesses to a parade of misery brought on by untreated mental illness.''

Leifman, an associate administrative judge, will recommend ways of separating the mentally ill from the criminal system. He said such people are vulnerable both as victims and offenders.

''Few other illnesses or conditions exist in which lack of care places the individual at such substantial risk of arrest, incarceration, homelessness and death, as the result of tragic, avoidable causes such as suicide, police-related shootings or other violent events,'' he said.

Lt. Gov. Jeff Kottkamp, Department of Juvenile Justice Secretary Walt McNeil, Department of Children and Families Secretary Bob Butterworth, and Richard Prudom, chief of staff of the Department of Corrections, joined the judges at a news conference in the Supreme Court rotunda. Lewis and Kottkamp, an attorney, said legislative leaders have also bought into the idea of improving programs for steering sick people away from jails and prisons.

Butterworth's predecessor, former Secretary Luci Hadi, resigned last year while under a contempt-of-court threat from a Tampa Bay-area judge who ordered the state to get mentally ill offenders out of county jails. It was one of the first issues Gov. Charlie Crist dealt with early this year.

''More than one-half of all prisoners and more than one-half of all those incarcerated in our jails have mental health or substance-abuse problems, or both,'' Lewis said. ''It's estimated that as high as 72 percent of jail inmates in the counties around the state have some type of mental-health issue or substance abuse disorder.''

He said there are more than 86,000 homeless people in Florida and that 20 percent of them have mental-health problems. Lewis said 30 percent of the homeless have alcohol or drug dependencies and that more than 70,000 people with mental impairments are arrested in Florida each year.

Lewis and Butterworth, a former circuit judge and attorney general, said the new initiative would not violate the legal separation of executive, legislative and judicial powers. Butterworth said DCF would work with DJJ, DOC and the courts to find solutions.

''This is an issue that transcends all of our departments,'' he said.

Lewis said Leifman's work will be funded through June with a $35,000 grant from the Florida Bar Foundation. He said he hopes the Legislature will provide for a continuing operation in the 2007-08 budget.